By the time I entered my intern year, I thought I'd had a lot of exposure to OB and childbirth care. After all, I'd done four rotations and delivered ten babies, a good record for a mere medical student. I had a few moments of pure hubris in thinking I'd seen enough to be ready for the large number of deliveries I was looking forward to doing at my program's hospital. In this post, I'll discuss what I learned about childbirth and maternity care in during my three-year family practice residency.
In the last post in this series, I described Hospital #4, where I did a fourth-year elective and ultimately where I matched for family practice residency. I won't repeat the description here, but I want to enlarge on a few elements of this hospital's patient population, practice style, and opportunities to explore childbirth and maternity care.
1. Patient population
Most of the people who came to Hospital #4 for services were Mexican farmworkers. Some lived near the hospital year-round, others stayed for part of the year then moved on, following harvest cycles into the Southwest. Approximately 85% of the pregnant women who had their babies at the hospital spoke Spanish exclusively, and a large percentage had no greater than the equivalent of a 6th grade education, meaning they were functionally illiterate in their own language. To say that providing optimal care to people with whom you share neither language nor educational foundation is a great challenge, to say the least.
2. High volume of births
Hospital #4 had 260 to 270 births per month during the years I was there. The residents cared for 95% of those mother-infant pairs. On any given day, we delivered up to twenty babies out of eight labor and delivery rooms. On busy days, women arrived and had to be seated in the hallway until a room or even a gurney in the triage area could be freed up. Residents ran from labor room to labor room, following the progress of multiple women in labor.
3. High acuity of pregnant patients
Our maternity patients included many low-risk pregnancies among healthy young women, but we also cared for a large number of women with gestational diabetes, pre-existing diabetes, chronic hypertension, thyroid disease, multiple gestation and Rh isoimmunization. A group of perinatologists held regular clinics at our hospital, sending a different maternal-fetal specialist each week from their home office in San Jose, sixty miles away.
Some examples of the complicated cases I helped manage during the three years I was a resident:
- A severe case of HELLP syndrome (a type of severe preeclampsia), with onset one hour after an uneventful vaginal delivery and complicated by rupture of the hepatic capsule. The patient required multiple trips to the OR to pack the liver capsule, and received all the blood products in three counties before she recovered.
- A significant case of Rh isoimmunization in a G7P5 mother who never received prenatal care in her earlier pregnancies. The infant had an uneventful birth but required exchange transfusion on day 5 of life.
- The Cesarean delivery of a 17 year old G1P0 with uncontrolled type II diabetes, whose infant was born with Goldenhar's syndrome.
Because of the acuity of the patients we saw, residents got to manage higher-risk pregnancies than they would have at other, less acute hospitals. There are a number of complications of pregnancy that I am quite comfortable managing--severe preeclampsia, gestational diabetes, some autoimmune diseases--because of this experience.
4. Limited community resources for pregnant women
As mentioned above, our pregnant patients often faced significant barriers to obtaining health care: low educational attainment, language/culture barriers, intermittent residency, and often undocumented immigration status. Unfortunately, the community had few resources to assist them in obtaining services beyond Medi-caid enrollment. Childbirth classes were held at a nearby adult school, but only a small minority of women were able to attend. A local doula group once gave a presentation to the residents, offering the advantages of labor support to improve outcomes and patient satisfaction. When we asked the speaker whether there were any doulas who spoke Spanish, she paused and said "None." So we never worked with doula-supported labor.
5. Wide range of obstetrical management
Women who had their babies at Hospital #4 received standard obstetrical care:
- Continuous external fetal monitoring
- IV fluids
- IV fentanyl written as part of routine admitting orders
- Augmentation of labor if no progressive dilation during the active phase of labor
- Internal fetal monitors if needed
- Induction of labor for post-dates pregnancy (usually initiated before 42 weeks)
- Induction of labor for accepted medical indications (preeclampsia, insulin-requiring gestational diabetes, cholestasis of pregnancy, etc.)
Within this limited palette of obstetrical management, our preceptors managed to develop their own personal styles and preferences. Some never broke down the bottom of the birthing bed, some always did. (Having a "bed delivery" was about as adventurous as our births got at Hospital #4.) Some encouraged routine episiotomies, which most residents resisted, and some taught perineal support techniques. There were a couple of extremely high-strung OB attendings who were much more interventionist that the average provider. I wrote several blow-by-blow accounts of nights on call, describing their style.
6. Limited access to obstetrical anesthesia
Although Hospital #4 had 24/7 in-house anesthesia, the anesthesiologist was on call for all OR cases and could not be dedicated to providing OB anesthesia. Effectively this meant we had no access to epidurals. I only witnessed two epiduralized labors out of the thousands I was involved with as a resident. This means the residents did witness non-epiduralized labor, if not completely unmedicated labor. A minority of women received no analgesia in labor at all, although without access to significant pregnancy support (such as doulas or childbirth education), a large number of women benefitted from small amounts of IV pain meds and intrathecal analgesia administered by residents after special training.
7. Childbirth care in parallel with full-spectrum family practice
Hospital #4 was a rural community hospital run by family practice residents and their attending physicians. Birth happened all the time, but so did death and the complexities of illness, routine and rare. We took care of adult and pediatric inpatients, as well as newborns. As a whole, the population was as acute as the pregnant women within it. (At the time, I posted a number of blow-by-blow accounts of call nights at my residency hospital. I encourage you to read them--poorly written as they were--to get a feeling for what our call was like.)
Following the progress of labor and birth against a backdrop of the other dramatic events going on within the hospital occasionally made birth seem more dangerous but often much more routine and benign than it might have appeared if our patients had been giving birth at Hospital #1, a large tertiary care Labor & Delivery unit very much insulated within the academic medical center.
LESSONS LEARNED AT HOSPITAL #4
How did my residency experiences influence the development of my approach to childbirth?
I learned you must care for all pregnant women equally in order for an individual woman to have a safe birth experience. This is something I learned during busy nights on Labor & Delivery, when we often had a baby born every hour. On nights like that, we could not individualize each woman's care, but we could provide high-quality, standard obstetric care to every woman who walked through our doors. I would love to say every woman we cared for had the birth experience of their dreams, but I suspect few did. My residency taught me that we must meet the needs of the many before we can tailor the experience for the ideals of a few. As I write this statement I realize it sounds clinical and heartless, but I believe it is my job as a family doctor who attends births in a hospital.
I learned birth takes place within a continuum of physical wellness and illness. The vast majority of births we attended were low-risk and resulted in a health mother/infant pair. However, I saw enough high-risk pregnancies and complicated outcomes to develop a healthy respect for the unpredictability of pregnancy.
Culturally competent care is an elusive goal, where resources are limited. Many times I wished for more access to childbirth education in Spanish for our mothers, and if I had any experience working with doulas at the time, I'm sure I would have wished for bilingual professional birth supporters as well. Yet often we worked with patients who had only a rudimentary knowledge base about their own bodies. I often astonished women when I explained they had not two, but three outlets in their genital region: one for urine, one for feces, and one for menstruation/giving birth. Thought I would have liked to give women an empowering birth experience, I found I spent most of my time providing a foundation in self-care and basic health awareness. I believe this was effort well-spent, and I hope the women I helped care for thought so too.
After leaving residency, I learned I had gained the skills I needed to practice confidently in a rural hospital, where I have OB backup but evaluate pregnant women and recommend care autonomously. I think this is an essential confidence to obtain early in a birth attendant's working life. Because I felt confident in providing the obstetrical model of care for pregnant woman, I have been able to explore my comfort level with childbirth practices outside the mainstream obstetrical model. In future posts in this series, I will discuss our Labor & Delivery unit, which is a unique setting in which we combine women-centered childbirth care with access to medical interventions when needed, and our patient population.